Concerns raised 1 Lack of identifiable beds for mentally disordered patients in cases of special urgency View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
David Reginald Bert Stacey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of identifiable beds for mentally disordered patients in cases of special urgency
Wider context from the report “An expert was instructed to advise on the psychiatric aspect of Mr Stacey’s death. One of the issues he identified was a failure to identify availability of a bed for cases of special urgency . This is a statutory requirement under section 140 of the Mental Health Act 1983 that the relevant health bodies (local Clinical Commissioning Group and Local Health Board) give advice to every social services authorities within the area of arrangements that are in force for the reception of mentally disordered patients in cases of special urgency . The expert was in no doubt that Mr Stacey would have fulfilled the ‘special urgency’ category. It transpires from my further communication with the Leicestershire Partnership Trust that there is no such facility in Leicestershire . It would appear to be a statutory requirement that is currently being ignored and I am concerned that another similar situation might arise when there are no beds available to or identifiable by, the local Trust .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare and publish a report supporting CCGs and local authorities to improve implementation of section 140 requirements.
Verbatim wording from the response “We are committed to improving the implementation of requirements under section 140 of the Mental Health Act and, in response to the findings in Sir Simon Wessely’s Independent Review of the Mental Health Act², we are preparing a report to support CCGs and local authorities to make these improvements. This will be published as soon as it is possible to do so.” Source location David-Stacey-Response-from-the-Department-of-Health-and-Social-Care
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities, providers, NHS commissioners, police and ambulance services are responsible for agreeing a joint local policy for section 140 admissions.
Verbatim wording from the response “On the use of section 140 beds, as you identify in your report, clinical commissioning groups (CCGs) have a duty to notify local authorities of the arrangements in place for the reception of patients in cases of special urgency. The Mental Health Act 1983: Code of Practice¹, includes guidance on how the use of section 140 beds should be managed locally. The Code makes clear that local authorities, providers, NHS commissioners, police forces and ambulance services should ensure that a clear, joint policy, is in place for the safe and appropriate admission of people in the local area in cases of special urgency. This should be agreed at board level and each party should appoint a named senior lead.” Source location David-Stacey-Response-from-the-Department-of-Health-and-Social-Care
Open published response
28 Dec 2018 Joan Wright · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 9 Poor management and documentation of medication View source Failure to prevent unauthorised access and repeated administration of Oramorph View source Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports View source Significant impact from excess administration of opioids at any prescribed strength View source Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports View source Failure to maintain consistent classification-based storage and handling arrangements for Oramorph View source Lack of a statutory definition of the required frequency of medication checks by care homes View source Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications View source Lack of designation of CCGs as bodies with statutory responsibility for drugs View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Joan Wright · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joan Wright, who had poor mobility and was unable to communicate verbally, died at Belmont Residential Home on 16 September 2017; the post-mortem found extensive coronary artery atheroma. The report raised concerns about the incorrect administration and handling of Oramorph, medication management at a care home rated inadequate, and failures to recognise and address safeguarding risks after the medication incident.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor management and documentation of medication
Wider context from the report “5. The home in question has been rated as inadequate by CQC and was under regular monitoring via an action plan. It was also being visited regularly by the Local Authority Quality Support Team every 10 days or so. One of the issues previously identified was poor management/documentation of medication . Notwithstanding that, access and unauthorised repeated administration of Oramorph took place;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unauthorised access and repeated administration of Oramorph
Wider context from the report “5. The home in question has been rated as inadequate by CQC and was under regular monitoring via an action plan. It was also being visited regularly by the Local Authority Quality Support Team every 10 days or so. One of the issues previously identified was poor management/documentation of medication. Notwithstanding that, access and unauthorised repeated administration of Oramorph took place ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of GMP call handlers to recognise safeguarding risks in opioid maladministration reports
Wider context from the report “4. GMP’s call handler did not recognise the potential safeguarding risks of the maladministration of opioids to a vulnerable member of the community and referred the report to the local division. The local division assessor (LRO) failed to recognise the safeguarding risks and filed the report as theft. GMP have changed their policies significantly since the matter was referred to them after Mrs Wright’s death. However it was unclear about whether or not the issue had been addressed by Forces nationally. The inquest was told that the CDLO role had been brought in after the Shipman inquiry to ensure safeguarding risks were identified in relation to maladministration of drugs;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Significant impact from excess administration of opioids at any prescribed strength
Wider context from the report “1. The inquest heard that Oramorph had different classifications depending on the strength prescribed. This impacts the storage/handling arrangements. The inquest heard that opioids can have a significant impact at whatever strength they are prescribed if given in excess ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of local division assessors to recognise safeguarding risks in opioid maladministration reports
Wider context from the report “4. GMP’s call handler did not recognise the potential safeguarding risks of the maladministration of opioids to a vulnerable member of the community and referred the report to the local division. The local division assessor (LRO) failed to recognise the safeguarding risks and filed the report as theft . GMP have changed their policies significantly since the matter was referred to them after Mrs Wright’s death. However it was unclear about whether or not the issue had been addressed by Forces nationally. The inquest was told that the CDLO role had been brought in after the Shipman inquiry to ensure safeguarding risks were identified in relation to maladministration of drugs;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain consistent classification-based storage and handling arrangements for Oramorph
Wider context from the report “1. The inquest heard that Oramorph had different classifications depending on the strength prescribed . This impacts the storage/handling arrangements . The inquest heard that opioids can have a significant impact at whatever strength they are prescribed if given in excess;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a statutory definition of the required frequency of medication checks by care homes
Wider context from the report “6. The CQC gave evidence that the legislation requires regular checks by care homes in relation to medication but there is no statutory definition of what regular means . As a result in some it is monthly in others weekly .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the CDLO to liaise with the local police unit and discuss safeguarding implications
Wider context from the report “3. Following the maladministration of medication to Mrs Wright, the inquest heard that the matter was reported to GMP .The CDLO investigated but did not liaise with the local police unit or discuss the safeguarding implications ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of designation of CCGs as bodies with statutory responsibility for drugs
Wider context from the report “2. Evidence was given that because of the abolition of PCT and replacement with CCG’s there was no designation of the CCG’s as designated bodies with statutory responsibility in relation to drugs . This was an oversight but has not been corrected ;
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deploy additional clinical pharmacists in primary care and care homes.
Verbatim wording from the response “In addition, as part of the Government's response to the World Health Organisation's patient safety challenge on medicines safety, we are developing a programme of work led by NHS Improvement to improve medicines safety. Work is underway to accelerate the roll-out of electronic prescribing to controlled drugs and medicines administration, and to deploy more clinical pharmacists in primary care and care homes. We have also introduced monitoring of the highest risk prescribing practice linked to hospital admissions.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
Verbatim wording from the response “You mention the Shipman Inquiry in your report. In response to the Shipman Inquiry's Fourth Report¹, there have been significant changes in the governance arrangements for the use and management of controlled drugs.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Accelerate rollout of electronic prescribing for controlled drugs and medicines administration.
Verbatim wording from the response “In addition, as part of the Government's response to the World Health Organisation's patient safety challenge on medicines safety, we are developing a programme of work led by NHS Improvement to improve medicines safety. Work is underway to accelerate the roll-out of electronic prescribing to controlled drugs and medicines administration, and to deploy more clinical pharmacists in primary care and care homes. We have also introduced monitoring of the highest risk prescribing practice linked to hospital admissions.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing controlled-drug governance measures are considered sufficient to detect and minimise inappropriate use, although they cannot prevent every incident.
Verbatim wording from the response “While no system can ever completely prevent the mismanagement or misuse of controlled drugs, we believe the measures that have been put in place mean that the inappropriate use of opioids and other controlled drugs can be detected more quickly and minimised, so that protracted poor practice is less likely to continue unchecked.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about police responses and national learning should be raised with the Home Secretary because Controlled Drug Liaison Officers are police employees.
Verbatim wording from the response “Your report raises concerns about the actions of Greater Manchester Police in responding to the potential safeguarding risks following the incident report of maladministration of Oramorph to Mrs Wright, and questions if learning from this incident has been shared at a national level.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Registered providers and managers are responsible for ensuring the proper and safe management of medicines in care homes.
Verbatim wording from the response “It is the registered provider and the registered manager’s responsibility to ensure the proper and safe management of medicines and guidance is available to support them to achieve this. The National Institute for Health and Care Excellence (NICE) has produced a national guideline on the ‘Safe use and management of controlled drugs’ (NG46)⁶, published in 2016, and a social care guideline (SC1), published in 2014, provides guidance on ‘Managing medicines in care homes’⁷. Furthermore, the CQC has clear guidance on its website on ‘Storing controlled drugs in care homes’⁸.” Source location 2018-0408-Response-by-Department-of-Health
Open published response
20 Dec 2018 Maria Katarina HRYNIW · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to establish clear responsibility for PEG feeding assessment and key decisions View source Failure to assess the suitability and volume of continued PEG feeding in the community View source Failure to hold a community MDT when prescribing end of life medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Maria Katarina HRYNIW · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maria Katarina HRYNIW, who was PEG fed following a stroke and had very limited mobility, developed bronchopneumonia and died at The Lakes Care centre on 14 April 2018. Concerns included the lack of assessment of the suitability and volume of continued PEG feeding near the end of life, continued administration despite reported difficulty coping with the prescribed volume, and unclear responsibilities between the SALT team and care home regarding assessment and decision-making.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to establish clear responsibility for PEG feeding assessment and key decisions
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to assess the suitability and volume of continued PEG feeding in the community
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her . The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it . A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to hold a community MDT when prescribing end of life medications
Wider context from the report “The inquest heard evidence that Maria Katarina HRYNIW was peg fed. She was approaching the end of life but there was no assessment regarding the suitability of the use of continued peg feeding in the community or the volume given to her. The inquest heard evidence from her family that she could not cope with the volume prescribed but continued to be given it. A community MDT was not held when she was prescribed end of life medications. Maria Katarina HRYNIW lacked capacity to refuse PEG feeding and it continued as the home felt that ethically and legally they had to continue as end of life care was in place. The inquest heard that some of the difficulties arose form an lack of understanding between the SALT team and care home about who would carry out assessment and who would make the key decisions regarding the use of peg feeding.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Verbatim wording from the response “You will appreciate that I am not in a position to comment on the quality of end of life care provided by the nursing home and others to Ms Hryniw. I expect the Care Quality Commission to respond to you as regulator of health and adult social care in England on its consideration of the matters of concern raised with regard to the provision of services in this case.” Source location 2018-0398-Response-by-Department-of-Health-and-Social-Care
Open published response
19 Dec 2018 Miss Kirsty Walker · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Miss Kirsty Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further deaths.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring prisoners to secure hospitals under s.47 of the Mental Health Act 1983
Wider context from the report “I am concerned that the average time to transfer a prisoner to a secure hospital under s.47 of the Mental Health Act 1983 is well in excess of the 14 days envisaged by the 2009 Bradley Report and presents a risk of further deaths.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS England is responsible for commissioning prison healthcare and secure mental health beds, so it must respond in detail.
Verbatim wording from the response “You issued your report to NHS England as well as the Department. NHS England is responsible for the commissioning of prison health care services and the commissioning of specialist mental health services, including secure adult mental health beds. It is therefore for NHS England to respond to you in detail. However, I am aware of, and hope you will be assured by, the work currently being undertaken by NHS England around improving access to mental health services, including secure inpatient care, for offenders with mental health difficulties.” Source location 2018-0396-Response-by-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The report does not establish the extent to which delayed transfer contributed to the death.
Verbatim wording from the response “I have noted the concerns raised in your report about the length of time it takes to transfer a prisoner to a secure hospital under section 47 of the Mental Health Act 1983¹ and the risk this poses to future deaths. It is not clear from the detail in the report as to the extent that this was a contributing factor in the death of Miss Walker. However, I acknowledge the evidence given at inquest in relation to this and the cause for concern of future deaths.” Source location 2018-0396-Response-by-Department-of-Health-and-Social-Care
Open published response
22 Nov 2018 Savannah-Rose Michelle Owen · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of specific safety regulation for multi-purpose nursing pillows View source Misleading warning leaflet imagery about leaving babies unattended on multi-purpose nursing pillows View source Failure to keep safety warnings attached to multi-purpose nursing pillows through resale or recycling View source Lack of assurance that health visitors and midwives flag the risks of babies being propped on multi-use pillows for naps View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Savannah-Rose Michelle Owen · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Savannah-Rose Michelle Owen was a healthy baby born on 16 February 2018 who fell asleep on a nursing pillow on a sofa at home on 22 April 2018 and later became unresponsive. Resuscitation attempts were unsuccessful, and the post-mortem found no cause of death, with the death recorded as due to natural causes. Concerns included the lack of specific safety regulation for multi-purpose nursing pillows, potentially misleading imagery and warnings, the warning label not being attached to the pillow, and uncertainty about whether community health professionals were highlighting the risks of unsupervised sleeping on such pillows.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of specific safety regulation for multi-purpose nursing pillows
Wider context from the report “1. Unlike many items associated with babies/young children such as high chairs/cots there was no specific safety regulation for such items . Instead manufacturers had to interpret the all-embracing safety policy. This risked inconsistent safety warnings/labelling ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Misleading warning leaflet imagery about leaving babies unattended on multi-purpose nursing pillows
Wider context from the report “3. On the warning/information leaflet were 5 pictures of a baby positioned on the pillow. In only 2 images was the baby with an adult. On the other 3 the baby was alone. The inquest was told that this could be misleading as to the importance of never leaving a baby unattended on the pillow ; and
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to keep safety warnings attached to multi-purpose nursing pillows through resale or recycling
Wider context from the report “4. The warning label was not attached to the item therefore; once the package had been opened, there was a high risk that the warning label would be lost . On resale/recycling of baby items this meant that second hand users/purchasers were unlikely to see the warning .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that health visitors and midwives flag the risks of babies being propped on multi-use pillows for naps
Wider context from the report “2. It was unclear if Health Visitors/ Midwives in the community seeing multi-use pillows being used were flagging up the risks of allowing babies to be propped on them for naps and that their use in such a way was wholly inconsistent with safe sleeping advice ;
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for nursing-pillow safety regulation rests with the Department for Business, Energy and Industrial Strategy.
Verbatim wording from the response “Firstly, I should clarify that nursing pillows are not classified as medical devices and are therefore outside the remit of the Medicines and Healthcare Products Regulatory Agency (MHRA). Safety regulation in this case is a matter for the Department for Business, Energy and Industrial Strategy and I note you have issued your report to the Secretary of State.” Source location 2018-0367-Response-by-Department-of-Health-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Nursing pillows are not medical devices, so their safety regulation falls outside the MHRA’s remit.
Verbatim wording from the response “Firstly, I should clarify that nursing pillows are not classified as medical devices and are therefore outside the remit of the Medicines and Healthcare Products Regulatory Agency (MHRA). Safety regulation in this case is a matter for the Department for Business, Energy and Industrial Strategy and I note you have issued your report to the Secretary of State.” Source location 2018-0367-Response-by-Department-of-Health-Social-Care
Open published response
Concerns raised 3 Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients View source Failure to enter timed ward-round dictated notes in chronological order View source Failure to record clinician input following escalation in clinical notes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Roy Burgess · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Roy Burgess, aged 87, was admitted after a fall at home that caused a left femoral fracture and was transferred for surgery. The report identified missed opportunities to recognise and escalate his deteriorating condition, inadequate clinical record-keeping, and untimed ward-round notes entered non-chronologically. The inquest concluded that it was unlikely that intervention would have altered the outcome.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the Early Warning System for identifying and escalating deteriorating patients
Wider context from the report “(1) The hospital Early Warning System used to identify and escalate a deteriorating patient was not adhered to. This allowed missed opportunities for Mr Burgess’s care to receive Senior Medical reviews which could have altered his management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to enter timed ward-round dictated notes in chronological order
Wider context from the report “(3) Finally, untimed dictated notes of ward rounds , were then entered into the records in a non-chronological order , which was unhelpful and potentially misleading
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinician input following escalation in clinical notes
Wider context from the report “(2) Inadequate record keeping by clinician within the Clinical notes. There were numerous examples of care having been escalated by nursing staff to doctors but no record of their input following this escalation was entered in the notes , e.g. on 4th December 2017, Mr Burgess’s care was escalated between 11:40 hours and 16:30 hours on at least 5 occasions and no entries were placed in his clinical records . This could have had a detrimental effect on his care and if this practice continues it will potentially affect other patients.
” Open source report
21 Nov 2018 Ursula Niamh MacEochaigh Keogh · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Failure to ensure CAMHS referral pathways remain operable where school psychology services are unavailable View source Failure to provide consistent referral advice between health and education professionals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ursula Niamh MacEochaigh Keogh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 22 January 2018, 11-year-old Ursula Niamh MacEochaigh Keogh left school, got off the bus early and jumped from North Bridge in Halifax; she was later found in the river and pronounced deceased. The inquest heard concerns about inconsistent advice and communication between health and education professionals regarding referral for assessment of Ursula’s self-harm, as well as preventative measures at North Bridge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure CAMHS referral pathways remain operable where school psychology services are unavailable
Wider context from the report “During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP, during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school, so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway , notwithstanding that at this time the school did not have the services of a Psychology team to make the referral .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent referral advice between health and education professionals
Wider context from the report “During the inquest I heard that Ursula’s mother contacted Ursula’s GP at Spring Hall Medical Centre by telephone on 13/11/17 in order to discuss her concerns about Ursula’s history of self-harm and that this resulted in her mother being advised by a GP to get Ursula’s school involved. Although the school subsequently advised Ursula’s mother to contact her GP , during the telephone conversation of 14/12/17 to further discuss Ursula’s self-harming, the GP advised her mother to contact the Psychology Team attached to the school , so that Ursula could be assessed for referral to Child & Adolescent Mental Health Team if necessary, in accord with the protocol previously issued by Calderdale CAMHS referral pathway, notwithstanding that at this time the school did not have the services of a Psychology team to make the referral.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide 24/7 crisis care access for children, young people and their families through NHS111 by 2023/24.
Verbatim wording from the response “You may also wish to note that the Government published the first cross-Government Suicide Prevention Workplan in January 2019 which set out an ambitious programme to reduce suicides, including in children and young people⁶. Furthermore, setting up 24/7 crisis care provision for children, young people and their families is a key priority for the Government in the NHS Long Term Plan⁷, published on 7 January 2019. All children and young people experiencing crisis will be able to access crisis care 24 hours a day, seven days a week by 2023/24 via NHS111.” Source location 2018-0370-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish Mental Health Support Teams in and near schools and colleges through 25 trailblazer sites to provide earlier support for children and young people.
Verbatim wording from the response “On 20 December 2018, the Government announced the first wave of 25 trailblazer sites that will test the plans set out in the Green Paper. These new plans will significantly increase the availability of mental health support to children and young people, including creating new Mental Health Support Teams working in and near schools and colleges to support children and young people with mild to moderate mental health conditions. Mental Health Support Teams will provide brand new” Source location 2018-0370-Response-by-Department-of-Health-and-Social-Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local NHS services and local authorities are responsible for responding to the concerns and learning from deaths to improve service safety.
Verbatim wording from the response “Your report raises three matters of concern and is directed to NHS Calderdale Clinical Commissioning Group (CCG) and Calderdale Council, as well as the Department of Health and Social Care. I am aware that the Calderdale CCG has responded to your concerns from a local perspective, advising you of a series of actions that are being undertaken in light of the report. We expect the local NHS to take action to respond to concerns and learn from deaths to ensure the safety of healthcare services and I am encouraged that the local NHS is looking into these matters carefully.” Source location 2018-0370-Response-by-Department-of-Health-and-Social-Care
Open published response
13 Nov 2018 Thomas Paul Arthur JACKSON · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 11 Failure of staff to recognise Clozapine significance, side-effects and warning signs of deterioration View source Lack of national policy for regular clozapine blood plasma-level testing View source Unclear lone-working procedures for entering patients’ rooms View source Poor recording of ward rounds or multi-disciplinary team meetings View source Inadequate patient participation in clinical meetings View source Difficulty disclosing significant patient documents during the Inquest process View source Unavailability of standard treatment and Clozapine smoking-risk information for patients and families View source Failure of appropriate personnel to attend clinical meetings View source Poor record keeping affecting continuity of care View source Inadequate consideration of patient history before clinical meetings View source Inaccuracies in serious incident reviews affecting process validity View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to recognise Clozapine significance, side-effects and warning signs of deterioration
Wider context from the report “(3) It is clear that Clozapine is a beneficial drug for many patients and that a large number of patients in the care of the Trust do receive this drug. However it appears that many staff are not aware of the significance of this medication particularly when considering potential side-effects and warning signs of deterioration .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national policy for regular clozapine blood plasma-level testing
Wider context from the report “It is well known that Clozapine is a potentially dangerous drug which needs to be carefully monitored. Monitoring is for both whole blood to look at infection markers and for blood plasma to cheek on Clozapine levels. Since this death the Trust involves has established a policy for the regular checking of blood plasma levels for patients in receipt of Clozapine. However it appears that this is a local policy and that there is no national policy for these checks to be carried out . I wonder if there should be a direction for all trusts to carryout blood plasma tests on patients receiving Clozapine on a regular basis perhaps at least six monthly or yearly.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unclear lone-working procedures for entering patients’ rooms
Wider context from the report “(5) I wonder if there needs to be a review of any lone-working policy or procedure with particular reference as to when to enter patients’ rooms .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor recording of ward rounds or multi-disciplinary team meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times , there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate patient participation in clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Difficulty disclosing significant patient documents during the Inquest process
Wider context from the report “(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process. Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of standard treatment and Clozapine smoking-risk information for patients and families
Wider context from the report “(4) I would not wish for patients or their families to be overloaded with paperwork but I wonder if there could be a simple leaflet available to patients and family members covering standard information about treatment generally but including matters such as the dangers of patients smoking whilst they are receiving Clozapine .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of appropriate personnel to attend clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting, failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping affecting continuity of care
Wider context from the report “(1) During the hearing it was noted that on a number of occasions record keeping was poor . This can make continuity of care difficult and it can lead to matters being missed. I wonder if the Trust can take any action to improve this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate consideration of patient history before clinical meetings
Wider context from the report “(2) It is apparent that patients do benefit from regular ‘ward rounds’ or ‘multi-disciplinary team meetings’ (there are a variety of titles) and, apart from the record of these meetings being very poor at times, there is a concern about the conduct of these meetings. In particular there appears to be on occasions inadequate consideration of the history in preparation for the meeting , failure of attendance of all appropriate personnel at such meetings and concern about the patient being able properly to participate.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in serious incident reviews affecting process validity
Wider context from the report “(6) It is well known that it is important for lessons to be learnt following serious incidents. The SIR procedure is a significant part of this. I understand there have been some changes since the time of Tom’s death but the SIR carried out in this matter contained a number of significant inaccuracies which can affect the validity of the process . Additionally although the records for patients who are in hospital for a long period of time can become voluminous there has also been some difficulty in disclosure of significant documents during the Inquest process.
” Open source report
24 Oct 2018 Maximilien Conrad Kohler · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 8 Inadequate NHS services for adults with ASD View source Lack of education for parents caring for children with ASD View source Severe shortage of inpatient psychiatric beds for children and adolescents View source Over-reliance on questionnaires impeding correct diagnosis View source Lack of support for parents caring for children with ASD View source Reduced training time for doctors causing delays in diagnosis and misdiagnosis View source NHS commissioning structure biased against services for chronic incurable conditions and ASD View source Over-reliance on questionnaires causing underestimation of self-harm risk View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Maximilien Conrad Kohler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maximilien Conrad Kohler, known as Max, was found hanging by a belt from a pull-up bar at his home on 5 May 2018 and died despite resuscitation. The report identified concerns about delayed or incorrect diagnosis, over-reliance on questionnaires in assessing diagnosis and self-harm risk, limited services and support for people with ASD and their parents, and shortages of NHS inpatient psychiatric beds for children and adolescents.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate NHS services for adults with ASD
Wider context from the report “6. That services for adults with ASD are even less well provided for by the NHS than those for children .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of education for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Severe shortage of inpatient psychiatric beds for children and adolescents
Wider context from the report “5. That there is a severe shortage of inpatient psychiatric beds for children and adolescents in the NHS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on questionnaires impeding correct diagnosis
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place , and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of support for parents caring for children with ASD
Wider context from the report “4. That there is a lack of support and education available for parents caring for children with ASD .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reduced training time for doctors causing delays in diagnosis and misdiagnosis
Wider context from the report “1. That delays in diagnosis and misdiagnosis in medicine due to reduced time in training for doctors in general and psychiatry in particular , may imperil the lives of vulnerable patients.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation NHS commissioning structure biased against services for chronic incurable conditions and ASD
Wider context from the report “3. That the NHS care commissioning structure is biased against the commissioning of services for chronic incurable conditions in general and ASD in particular .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Over-reliance on questionnaires causing underestimation of self-harm risk
Wider context from the report “2. That over reliance in the current fashion on questionnaires used in diagnostics and management may impede rather than assist doctors and other clinicians, firstly to arrive at the correct diagnosis in the first place, and secondly to cause or contribute to underestimation or proper evaluation of the risk of self -harm in particular .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make improved guidance and a best-practice toolkit available to commissioners for autism diagnosis and post-diagnosis services.
Verbatim wording from the response “In addition, in Spring this year, we will make available new and improved guidance for health and care commissioners and a best practice toolkit to improve diagnosis and post-diagnosis services for all people with autism.” Source location 2018-0316-Response-by-Department-of-Health-Social-Care
Open published response
18 Oct 2018 Joseph James GRANTHAM · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to provide community health professionals with clear instructions for head-circumference monitoring and action View source Unavailability of paper clinical notes to clinicians at appointments View source Delays in sending post-outpatient clinical letters and requests for assessment View source Failure to maintain a complete composite child health record in the red book View source Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs View source Failure of information systems to make key clinical information available across trusts View source Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Joseph James GRANTHAM · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide community health professionals with clear instructions for head-circumference monitoring and action
Wider context from the report “4. Joseph had been diagnosed by the neurosurgeons at RMCH with neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation. A recognised complication is hydrocephalus. Identification of the onset of hydrocephalus is through measurement of head circumference. The inquest heard that when Joseph was discharged from St Mary's the neurosurgical team did not send written instructions to community health professionals explaining what was required and why it was required. The midwives measuring his head were unsure why they were measuring it or what to do with the information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unavailability of paper clinical notes to clinicians at appointments
Wider context from the report “3. At ENT appointments and neurosurgery appointments at the RMCH, Joseph was seen without the paper notes because they had not been made available to the clinicians seeing Joseph.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in sending post-outpatient clinical letters and requests for assessment
Wider context from the report “2. Joseph was under the care of the paediatric neurosurgical team at the Royal Manchester Children's Hospital (RMCH). Letters from the neurosurgical team following out-patient appointments took 4 weeks to be sent out. As a result one letter to a paediatric anaesthetist asking for an examination was not typed until after the operation was due to take place. When his mother took him for review, she had to escalate the need for him to be seen by the paediatric anaesthetist who then deemed him not fit at that time for surgery.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a complete composite child health record in the red book
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a defined protocol for transfer of paediatric care between tertiary centres and DGHs
Wider context from the report “5. Joseph's health needs relating to neural tube defect (cervical meningocele, hydrocephalus, Arnold Chiari type II malformation and laryngomalacia were dealt with by the RMCH. His paediatric care was transferred without discussion by St Mary's back to the DGH. The inquest was told that there is no set protocol/ procedure between tertiary centres and DGH's for this situation, which can lead to differing practices.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of information systems to make key clinical information available across trusts
Wider context from the report “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician
Wider context from the report “1. After his birth Joseph was transferred to the neonatal unit at St Mary's due to the complexities of his health. Following his discharge, it took 6 weeks for the trust to send the discharge paperwork to the GP and the District General Hospital (DGH) to whom they were transferring his paediatric care. As a result, there was no clear understanding amongst health professionals as to the paediatrician with responsibility for his care . Letters were therefore copied into a mixture of paediatricians. The discharge letter to the DGH was addressed to a consultant who was in fact a registrar at the trust.
” Open source report
9 Oct 2018 Alba May Pemberton · Prevention of Future Deaths report North London
View report summary
Concerns raised 6 Failure to provide obstetric review for every birthing centre patient View source Insufficient close collaboration among obstetric staff in managing low-risk cases View source Failure to use CCG equipment when meconium is present View source Lack of MDT meetings between obstetric and midwifery staff View source Failure to classify meconium as meconium rather than grading its presence View source Insufficient obstetrician involvement in the management of low-risk cases View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alba May Pemberton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alba May Pemberton was born on 10 August 2016 after experiencing hypoxia during the active second stage of delivery and lived for two days. The report identified delayed five-minute heart monitoring and the possible absence of earlier CTG monitoring as concerns, noting that earlier detection and delivery might have resulted in survival. Concerns also included the classification of meconium, use of CTG equipment, obstetric review at birthing centres, and closer multidisciplinary working.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide obstetric review for every birthing centre patient
Wider context from the report “That every patient at a birthing centre should be the subject of obstetric review
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient close collaboration among obstetric staff in managing low-risk cases
Wider context from the report “There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to use CCG equipment when meconium is present
Wider context from the report “The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of MDT meetings between obstetric and midwifery staff
Wider context from the report “There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to classify meconium as meconium rather than grading its presence
Wider context from the report “The presence of meconium should be classified as meconium, and not graded , and once present should result in the use of CCG equipment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient obstetrician involvement in the management of low-risk cases
Wider context from the report “That obstetricians should be more involved in the management of low risk cases
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing NICE guidance and escalation protocols are considered sufficient without routine obstetric involvement in low-risk birth care.
Verbatim wording from the response “CG190 does not recommend an obstetric review or that obstetricians should be more involved in low risk births.” Source location 2018-0288-Response-by-Department-of-Health-Social-Care
Open published response
28 Sep 2018 Donald Berry · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of relevant authorities to identify high voltage power lines over event sites View source Lack of nationally replicated site visits for large events View source Failure to identify high voltage power lines over event sites View source Failure to minimise risks from high voltage power lines over event sites View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Donald Berry · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant authorities to identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue . Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally replicated site visits for large events
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to minimise risks from high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” Open source report
27 Sep 2018 Sheila Ann Hadfield · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Lack of suitable care beds for individuals with complex mental health needs View source Failure of the care home to meet residents’ complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Sheila Ann Hadfield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sheila Ann Hadfield, who had paranoid schizophrenia and lived in a residential care home, was found on the floor of her room and transferred to hospital, where the report states that she died from sepsis. The principal concern was that the care home struggled to meet her complex mental health needs and that there was a national shortage of suitable alternative placements.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable care beds for individuals with complex mental health needs
Wider context from the report “1. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs. However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs . The majority of available care provision was dementia beds which would have been unsuitable . The inquest was told that this meant that had Mrs Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the care home to meet residents’ complex mental health needs
Wider context from the report “1. The inquest heard that the home that Mrs Hadfield was placed in struggled to cope with her needs . However, there was a national shortage of suitable beds for individuals of a similar age to Sheila Hadfield with her complex mental health needs. The majority of available care provision was dementia beds which would have been unsuitable. The inquest was told that this meant that had Mrs Hadfield not remained where she was she would have had to go onto a mental health ward on a voluntary basis or been sectioned if she had refused.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local areas are responsible for determining arrangements to improve mental health care in care homes according to local need and service configuration.
Verbatim wording from the response “Building on the experience of the Vanguard sites, the development of Integrated Care Systems (ICSs) and Sustainability and Transformation Partnerships (STPs) provides a valuable opportunity to strengthen collaboration between health and social care services in a local footprint, and to help improve the provision of mental health care in care homes. Such arrangements are for local areas to determine, according to the local need and the make-up of local services.” Source location 2018-0334-Response-by-Department-of-Health-Social-Care
Open published response
27 Sep 2018 Mary Barbara Ryder · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to emphasise review of post-operative prophylaxis after discharge home View source Lack of guidance for extending clexane prophylaxis when patient mobility remains reduced View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mary Barbara Ryder · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Barbara Ryder underwent surgery for bladder cancer and was discharged after receiving Clexane, with reduced mobility and no further clinical review regarding Clexane. She later deteriorated, was diagnosed with a pulmonary embolism and died on 21 August 2017. The inquest raised concerns that guidance did not address whether some patients with ongoing reduced mobility might require longer treatment or emphasise review after discharge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to emphasise review of post-operative prophylaxis after discharge home
Wider context from the report “The inquest heard that:
The guidance nationally is to prescribe clexane for 28 days after an operation. However, the guidance does not suggest that some cases may require longer where a patients mobility remains reduced. There does not appear to be an emphasis on the need to review the situation throughout the post-operative period after a discharge home .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for extending clexane prophylaxis when patient mobility remains reduced
Wider context from the report “The inquest heard that:
The guidance nationally is to prescribe clexane for 28 days after an operation. However, the guidance does not suggest that some cases may require longer where a patients mobility remains reduced . There does not appear to be an emphasis on the need to review the situation throughout the post-operative period after a discharge home.
” Open source report
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NICE concluded that its VTE guidelines are appropriate and require no amendment at this time.
Verbatim wording from the response “My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) on the matter of concern you have raised.” Source location 2018-0323-Response-by-Department-of-Health-Social-Care
Open published response
26 Sep 2018 Bridget Marie Connell-Graham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of a clear definition of cervical trauma resulting in inconsistent assessment and pregnancy treatment planning View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Bridget Marie Connell-Graham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Bridget Marie Connell-Graham was born prematurely at 20 weeks’ gestation on 1 February 2018 and died at Tameside General Hospital from extreme prematurity. The inquest heard concerns about the lack of a clear definition of cervical trauma in NICE guidance, resulting in inconsistent national approaches to investigating such histories and planning clinical treatment during pregnancy.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear definition of cervical trauma resulting in inconsistent assessment and pregnancy treatment planning
Wider context from the report “A history of cervical trauma was contained within the maternal notes. The inquest heard that whilst there is guidance from NICE as to the appropriate action to be taken where there is a history of cervical trauma there is no clear definition of what amounts to cervical trauma . The inquest was told that this means there is an inconsistent approach nationally as to what will be treated as a history of cervical trauma and therefore in what steps are taken in relation to investigating a previous history of cervical trauma and planning clinical treatment during pregnancy .
” Open source report
26 Sep 2018 Angela Mary Jackson · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to provide accurate referral destination information for aortic aneurysm treatment View source Lack of approved documented pathways for referral and treatment of aortic aneurysms View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Angela Mary Jackson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Angela Mary Jackson died at the Royal Albert Edward Infirmary, Wigan, after being admitted with chest and abdominal pain and found to have an extensive thoracic aortic aneurysm. She suffered a cardiac arrest and died while discussions about referral to an appropriate specialist centre were ongoing. The report identified concerns about incorrect and delayed referrals and the absence of clear, documented pathways for managing and referring patients with aortic aneurysms.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate referral destination information for aortic aneurysm treatment
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England, although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem, which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of approved documented pathways for referral and treatment of aortic aneurysms
Wider context from the report “i. The treatment of an aortic aneurysm depends on the position of the aneurysm. In general terms aneurysms above the diaphragm are referred to as thoracic aneurysms and should be treated by cardiothoracic surgeons and aneurysms below the diaphragm are referred to as abdominal aneurysms and should be treated by vascular surgeons.
The treatment of a thoracic aneurysm by a Cardiothoracic Surgeon may also depend on the position of the aneurysm above the diaphragm. An ascending thoracic aneurysm could be dealt with by local Cardiothoracic Surgeons at the Wythenshawe Hospital in Greater Manchester, whereas a descending thoracic aneurysm should be referred to and managed by the Regional Aortic Centre in Liverpool, namely the Liverpool Hospital.
ii. The Wythenshawe Hospital referred to the Liverpool Hospital as the Liverpool Heart Centre and advised the Wigan Hospital to contact the Liverpool Heart Centre. Clearly, the Liverpool Heart Centre does not exist and the correct referral should have been to the Liverpool Heart and Chest Hospital.
iii. There are no written protocols or pathways in relation to the treatment of aortic aneurysms in Greater Manchester or the North West of England , although the Preston Hospital has started to prepare a written Acute Aortic Syndrome Pathway. However, the Acute Aortic Syndrome Path is only in draft form, which has not been approved and which is not in existence.
iv. The absence of documented pathways in relation to the treatment of aortic aneurysms is a national problem , which needs to be addressed to enable local district hospitals to be aware of the pathway and to have clear, unequivocal direction for referral of patients with appropriate and correct lines of referral, including the correct names of hospitals and direct telephone numbers and email addresses to ensure efficient and expedient referrals to appropriate hospitals and appropriate surgical teams.
v. The referral of patients for the treatment of aortic aneurysm, in many cases, requires an urgent referral and emergency treatment and in my opinion there is a risk that future deaths will occur unless action is taken to consider clear and unequivocal pathways for the referral of patients requiring such treatment.
” Open source report
26 Sep 2018 John Waite · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Lack of national guidelines for central venous catheter removal View source Electronic clinical notes permitting alteration of author times View source Failure to provide constant visual observation after central venous catheter removal View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
John Waite · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidelines for central venous catheter removal
Wider context from the report “iv. There are no national guidelines in relation to the removal of central venous catheters, particularly temporary central venous catheters for haemodialysis. The evidence at the Inquest confirmed that the Secretary of State, the Renal Association, the British Renal Society and the Intensive Care Society would be appropriate organisations to consider the issue of a national policy, protocol and guidance relating to the removal of central venous catheters.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Electronic clinical notes permitting alteration of author times
Wider context from the report “4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note . The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide constant visual observation after central venous catheter removal
Wider context from the report “ii. The Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters in existence within the Salford Royal NHS Foundation Trust at the time of the death included the fact that pressure should be applied for approximately 5 minutes after removal of the catheter or until bleeding has stopped and a patient should lie flat or supine for 30 minutes after removal of the catheter (if medically safe to do so). The guidelines did not state that a patient requires visual observation for a period of time following the removal of the catheter.
iii. Following the death of the Deceased the Salford Royal NHS Foundation Trust has taken action to address the concerns in relation to the Central Venous Catheter Insertion Management and Removal Policy for Short Term Catheters, together with the ongoing training of staff who undertake the removal of catheters and the management of rare complications.
A quick reference guide has been issued to staff by the Hospital in relation to the removal of catheters at the Hospital. The guide requires the patient to remain supine for 30 minutes post removal of the catheter with further bed rest for 2 hours post removal and a visual inspection of the dressing every 5 minutes during the period of 1 hour following the removal. However, the guide does not require constant visual observation for a period of time following the removal of the catheter.
The evidence at the Inquest was that, if there is haemorrhage following the removal of a catheter, blood loss could amount to 200mls every minute so that in the period of 5 minutes between each 5-minute inspection of the dressing, advised by the guidance, one litre of blood could be lost, which could lead to death.
The evidence at the Inquest was that a period of constant visual observation is required for a period of up to one hour following the removal of a catheter to reduce the risk of blood loss rather than simply monitoring by inspecting the dressing every 5 minutes for that period of time.
” Open source report
8 Aug 2018 Ian Paul Wolstenholme · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Potential for serious harm or death from combined drug toxicity associated with polypharmacy View source Lack of guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ian Paul Wolstenholme · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ian Paul Wolstenholme was found collapsed at home on 17 December 2017 and died later that day. The medical cause of death was combined drug toxicity, with liver cirrhosis and diabetes mellitus also contributing. The report raised concern about the lack of guidance for prescribing highly addictive and potentially harmful drugs together, particularly in cases of polypharmacy.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Potential for serious harm or death from combined drug toxicity associated with polypharmacy
Wider context from the report “1. During the course of the evidence, it became apparent that there is no guidance – national or otherwise - available to Clinicians such as GPs, Hospital doctors etc. on the how best to approach the prescribing of highly addictive and potentially very harmful drugs alongside one another. In this case, the deceased had been legitimately prescribed three different types of neuropathic analgesia (including Pregabalin), alongside other opiate based medications. Whilst such drugs are almost always prescribed for very good clinical reason/s, this type of polypharmacy gives rise to the potential risk of serious harm/death . I believe that guidance would help to prevent future deaths from combined drug toxicity .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another
Wider context from the report “1. During the course of the evidence, it became apparent that there is no guidance – national or otherwise - available to Clinicians such as GPs, Hospital doctors etc. on the how best to approach the prescribing of highly addictive and potentially very harmful drugs alongside one another . In this case, the deceased had been legitimately prescribed three different types of neuropathic analgesia (including Pregabalin), alongside other opiate based medications. Whilst such drugs are almost always prescribed for very good clinical reason/s, this type of polypharmacy gives rise to the potential risk of serious harm/death. I believe that guidance would help to prevent future deaths from combined drug toxicity.
” Open source report
30 Jul 2018 Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Failure to request police assistance for welfare checks when ambulance resources are constrained View source Delays in making and chasing-up welfare calls View source Failure to re-categorise incidents when welfare-call information indicates increased risk View source Failure of demand analysis to accurately estimate required ambulance capacity View source Unrealistic target turnaround time for ambulances at A&E View source Failure of call handlers to establish relevant overdose risk information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mr Richard Thomas Peter Barrett · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
On 20 April 2018, Mr Richard Thomas Peter Barrett took a large overdose of medication with alcohol, called 999 for help, and died before an ambulance reached his flat. Concerns included underestimated ambulance demand, delays in welfare checks and ambulance dispatch, unrealistic hospital turnaround targets, and the failure to ask police to conduct a welfare check.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to request police assistance for welfare checks when ambulance resources are constrained
Wider context from the report “(4) The police could have been asked to perform a welfare check.
Evidence showed that the Ambulance Trust is pessimistic in assuming that the police are also under-resourced and would not be able to assist in such a task. Here the police were not even asked if they could help. Had he been found earlier, whether by police or ambulance, there is a chance that the deceased may have been able to be given first aid and had a better chance of survival.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Delays in making and chasing-up welfare calls
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back . It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to re-categorise incidents when welfare-call information indicates increased risk
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of demand analysis to accurately estimate required ambulance capacity
Wider context from the report “(1) ‘Demand analysis’ seriously underestimated the number of ambulances required in Cardiff and the Vale that night.
Evidence showed that only 7 ambulances were available up until 2am, then 5 available up until 3am . Also 7 hours of ambulance time was lost during the period 02:26 – 06:30 due to delays at A&E.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Unrealistic target turnaround time for ambulances at A&E
Wider context from the report “(3) The target turnaround time for ambulances at A&E is wildly unrealistic.
Evidence showed that both the University Hospital of Wales and Llandough Hospital were averaging 3 times the target of 15 minutes that night with the longest turnaround being over 100 minutes . Such delay must have a knock-on effect upon the ‘demand analysis’.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of call handlers to establish relevant overdose risk information
Wider context from the report “(2) There does not seem to be a reliable system for the making and chasing-up of ‘welfare calls’.
Evidence showed that it was not until 2 hours 45 minutes after the initial call that an attempt was made to ring the patient back. It was known that the patient had taken a massive overdose of sleeping tablets at 01:50. It was not enquired by the call handler as to whether he had also taken alcohol, or whether he was alone. When there was no response from his telephone at 05:13 there was a missed opportunity to re-categorise the incident.
” Open source report
26 Jul 2018 Daniel Young · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 1 Failure of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Young · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Young, a fit and healthy university lecturer, was randomly attacked on his way to work on 19 January 2016 and sustained a fatal stab wound to the abdomen. The report raised concerns that GP surgeries did not routinely monitor whether psychiatric patients collected their antipsychotic medication, despite the risk that stopping treatment could lead to relapse and harm to others.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of GP surgeries to routinely monitor psychiatric patients’ collection of antipsychotic medication
Wider context from the report “2. GP surgeries do not routinely monitor that psychiatric patients are collecting their antipsychotics . Evidence revealed that it is not uncommon for such patients to stop their medication and relapse. Relapse puts them at a risk of harm to themselves and, sometimes, they pose a risk to others.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore with NHS Digital opportunities for primary care systems to alert GPs about prescription collection issues for named patients and drugs.
Verbatim wording from the response “• NHS England will explore with NHS Digital what opportunities there are for primary care clinical systems to alert GPs around prescription collection issues for named patients and named drugs; and” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ask GP practices to consider mechanisms for monitoring collection of antipsychotic medication prescriptions.
Verbatim wording from the response “• NHS England will write to GP practices to make them aware of this issue and to consider what mechanism they do or could employ to monitor the collection of antipsychotic medication prescriptions;” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Write to GP practices about monitoring collection of antipsychotic medication prescriptions.
Verbatim wording from the response “In the interim, NHS England has confirmed that it will undertake the following actions by the end of the year to address the issues noted in your report:” Source location 2018-0240-Response-by-Department-of-Health-Social-Care
Open published response
25 Jul 2018 Robert Thomas Wrinch · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 6 Incompatibility of pathology information technology systems between hospital trusts View source Lack of tracking of pathology samples and reports View source Failure of departments to track outstanding pathology reports View source Backlogs delaying pathology sample analysis View source Reliance on delayed paper delivery of pathology reports View source Failure to document conversations with other clinicians View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Robert Thomas Wrinch · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Incompatibility of pathology information technology systems between hospital trusts
Wider context from the report “4. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other . This meant that transfer of information between trusts to obtain a second opinion were more difficult .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of tracking of pathology samples and reports
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples . As a result, it was unclear when samples had been received and analysis had taken place . There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear . It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician . It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of departments to track outstanding pathology reports
Wider context from the report “3. At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not . As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Backlogs delaying pathology sample analysis
Wider context from the report “5. The Inquest heard that the delay in analysis of the sample taken was due to a backlog . The backlog was not unique to the Trust and such backlogs were prevalent across pathology departments nationally due to a local and national shortage of pathologists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Reliance on delayed paper delivery of pathology reports
Wider context from the report “2. The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via internal mail to the treating clinicians . The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to document conversations with other clinicians
Wider context from the report “1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events . Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread.
” Open source report
25 Jul 2018 Aniyah Jasmine Winston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of multidisciplinary team members to challenge incorrect clinical decisions View source Lack of routine pre-delivery scanning for breech presentation View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Aniyah Jasmine Winston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Aniyah Jasmine Winston was delivered vaginally in an undetected breech presentation and was in poor condition at birth after manipulation during delivery. Resuscitation was commenced and ceased at 10:59am. The concerns included the challenges of undetected breech births and the administration of Syntocinon without further review, examination, counselling or a written prescription; professionals involved reportedly felt unable to challenge the decision.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of multidisciplinary team members to challenge incorrect clinical decisions
Wider context from the report “2. The inquest was told by a number of medical professionals involved in Aniyah's birth that they whilst they felt the decision to give Syntocinon was incorrect they did not feel comfortable challenging the decision . The expert instructed was clear that at the time it was given it should not have been . The Trust has since the death of Aniyah put in place a detailed programme to improve confidence in challenging decision-making within a MDT setting. However the extent of recognition of the issue and steps to counter it nationally were unclear.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of routine pre-delivery scanning for breech presentation
Wider context from the report “1. The inquest heard that Aniyah was an undetected breech birth. By the time it was identified she was breech her mother was fully dilated. The inquest heard that there are undetected breech births are not uncommon and present particular challenges for those involved in care during labour. The inquest was told that it is the case that pre delivery scans are not routinely carried out to try and reduce the number of undetected breeches and midwives/doctors rely on external examination. The inquest was told that this is due to availability of scanning facilities and training to utilise the scanners .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine third-trimester scans are not recommended because no evidence supports them; lack of equipment or training is not the reason they are absent.
Verbatim wording from the response “On the first matter of concern, I can confirm that it is not the case that a lack of equipment or training accounts for a lack of pre-delivery scans to detect fetal malpresentation. Rather, it is that there is currently no evidence base to recommend routine third trimester scanning.” Source location 2018-0241-Response-by-Department-of-Halth-Social-Care
Open published response
25 Jul 2018 Jane Olive Parker · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of the diet preparation system to provide food in the correct format before serving View source Lack of care assistant understanding of modified diets and adherence requirements View source Lack of regular kitchen sorting and marking of food for residents with specific dietary requirements View source Lack of care assistant understanding and systems for escalating choking episodes to SALT View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jane Olive Parker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jane Olive Parker, who had dementia and a history of choking episodes, was found unresponsive approximately 40 minutes after eating an inappropriate meal unobserved in her room on 24 August 2016. Post-mortem examination found un-chewed food in her airway, and the recorded conclusion was death from aspiration of food, contributed to by neglect. Concerns included poor understanding and preparation of modified diets, and failures to escalate choking episodes to the Speech and Language Team for reassessment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure of the diet preparation system to provide food in the correct format before serving
Wider context from the report “2. Within the care home the system for preparing the correct diets types was such that food would come up to be served and would then need to be put into the correct format by the care staff . There was no regular system of the kitchen sorting and marking food to be served for individual residents with specific dietary requirements such as Mrs Parker. Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure care homes and their kitchens ensured clearly marked food was provided for residents with modified diets;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of care assistant understanding of modified diets and adherence requirements
Wider context from the report “1. There was poor understanding by the care home assistants of what was meant by the types of modified diets that could be recommended by the SALT teams . Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve knowledge within their care homes but it was unclear if there were national programmes to ensure that care assistants understood modified diets and the importance of adherence to them ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of regular kitchen sorting and marking of food for residents with specific dietary requirements
Wider context from the report “2. Within the care home the system for preparing the correct diets types was such that food would come up to be served and would then need to be put into the correct format by the care staff. There was no regular system of the kitchen sorting and marking food to be served for individual residents with specific dietary requirements such as Mrs Parker . Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure care homes and their kitchens ensured clearly marked food was provided for residents with modified diets ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of care assistant understanding and systems for escalating choking episodes to SALT
Wider context from the report “3. In Mrs Parker’s case the Inquest heard that there were opportunities to escalate her case back to SALT after choking episodes. However there was limited understanding within the care home assistants of the need to report and escalate choking episodes to ensure that the SALT team provided expert input and reduced risk. Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure that there were appropriate systems in place to ensure that there were appropriate escalations to SALT .
” Open source report
20 Jul 2018 Kathleen Gabrielle Bamforth · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 2 Lack of routine blood screening for long-term clomipramine treatment View source Potentially unsafe clomipramine prescribing practices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen Gabrielle Bamforth · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kathleen Gabrielle Bamforth was found unresponsive at home on 28 May 2017 and was confirmed to have died after resuscitation attempts. The cause of death was recorded as the effects of clomipramine toxicity, although the circumstances of the toxicity remained unclear. The substantive concerns were about reviewing prescribing guidelines for clomipramine and considering routine blood screening for patients receiving it long term.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Lack of routine blood screening for long-term clomipramine treatment
Wider context from the report “• To review current practice guidelines with respect to the prescription of clomipramine
• To consider the merits of routine blood screens in patients prescribed with long term use of clomipramine.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Potentially unsafe clomipramine prescribing practices
Wider context from the report “• To review current practice guidelines with respect to the prescription of clomipramine
• To consider the merits of routine blood screens in patients prescribed with long term use of clomipramine.
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing product information and NICE guidance provide monitoring and toxicity-risk controls; routine clomipramine blood-level screening is not currently recommended.
Verbatim wording from the response “On the matter of clinical guidelines, NICE has advised that its guidelines set out the expectation that prescribers will use a drug's Summary of Product Characteristics (SmPC), as well as the 'British National Formulary' (BNF) to inform decisions made with individual patients.” Source location 2018-0247-Response-by-Department-of-Health
Open published response
20 Jul 2018 Ruth Marian Perkin · Prevention of Future Deaths report Coventry
View report summary
Concerns raised 2 Insufficient staffing to provide required supervision for residents at risk of falls View source Failure to ensure care needs are assessed before discharge to the care home View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Ruth Marian Perkin · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing to provide required supervision for residents at risk of falls
Wider context from the report “(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care .
(5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night , and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed, actually placed her at an increased risk of falls and death as a result .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department of Health and Social Care; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure care needs are assessed before discharge to the care home
Wider context from the report “(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care .
(5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night, and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed , actually placed her at an increased risk of falls and death as a result.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations